A girl, who was injured by what activists said was shelling by forces loyal to Syria's President Bashar al-Assad, stands at the entrance of her house in the Douma neighborhood of Damascus, Syria, November 22, 2015.
A girl, who was injured by what activists said was shelling by forces loyal to Syria's President Bashar al-Assad, stands at the entrance of her house in the Douma neighborhood of Damascus, Syria, November 22, 2015.
Bassam Khabieh / Reuters

Conducting humanitarian operations in war zones is inevitably challenging. Delivery of effective aid demands adherence to the four key humanitarian principles laid out by the International Federation of Red Cross and Red Crescent Societies in 1965. The first two, humanity (alleviating suffering) and impartiality (prioritizing those in greatest need), are ethical principles that make the difference between merely doling out charity and providing humanitarian relief. The second two, neutrality (not taking sides) and independence (from the government), are pragmatic principles for operating in conflict settings. In combination with international humanitarian law governing the conduct of warring parties, which affirms the right to give and receive assistance, the four principles generate the humanitarian space required to operate in war zones.

Providing humanitarian relief during civil wars (as opposed to international conflicts) is particularly difficult—perhaps never more so than during the war in Syria, where the government’s military strategy relies on attacking civilians in opposition-held areas in an effort to render life there impossible. Since getting aid to those in greatest need contradicts the government’s goal of maximizing civilian suffering in opposition-held territory, Damascus has continued to do everything it can to obstruct relief—asserting sovereignty at the diplomatic level while targeting doctors, hospitals, ambulances, and convoys on the ground. Not only does the government deny humanitarian workers access to suffering populations, it denies that it is denying access. It tries hard to justify its targeting and obstruction by insisting that there are no civilians left in opposition-held areas, just terrorists. Yet recent pictures of children starving to death in Madaya, where 40,000 civilians are under siege by the government, undermine the government’s obscene arguments.

It isn’t just the Syrian government that is increasing civilian suffering, though. The way some United Nations agencies are running their humanitarian operations causes harm, too.


Syria, the world’s largest humanitarian crisis, is also the most expensive. OCHA, shorthand for the Office for the Coordination of Humanitarian Affairs, is the UN agency tasked with managing such crises, along with determining the global humanitarian budget, more than $20 billion in 2016, and allocating funds received from donor governments. OCHA’s forecast for 2016 is $3.2 billion for Syria alone, where it estimates that 13.5 million people are in need of humanitarian aid. Another $4.8 billion is solicited for the regional cost of putting up some four million refugees in Jordan, Lebanon, and Turkey.

A Kurdish Syrian refugee waits for transport during a sand storm on the Turkish-Syrian border near the southeastern town of Suruc in Sanliurfa province, September 24, 2014.
A Kurdish Syrian refugee waits for transport during a sand storm on the Turkish-Syrian border near the southeastern town of Suruc in Sanliurfa province, September 24, 2014.
Murad Sezer / Reuters
Yet five years into the Syrian crisis, long-festering concerns over OCHA’s lack of neutrality are growing. Characteristic of many agencies of the United Nations, OCHA places a premium on maintaining good relations with the Syrian government, a position fueled by its desire to stay in Damascus. With no end to the conflict in sight, though, it is worth asking whether OCHA’s bottom line is harming the agency’s efforts to alleviate the catastrophic consequences of Damascus’ anti-civilian strategy. Indeed, the 2016 UN plan for Syria provides a real-time illustration of what happens when a UN agency loses sight of humanitarian principles and prioritizes relations with a government intent on violating them.

The UN plan must be understood in the context of Syria’s incredibly complicated humanitarian situation. The most recent estimates place 800,000 civilians under siege, denied access to safe water, food, health care, fuel, and warmth. Of these, more than 600,000 civilians are besieged by the government. An additional 200,000 civilians are held by the self-proclaimed Islamic State (also known as ISIS) in the city of Deir ez-Zor. OCHA relies on permission from the government to gain access to these people, but the government rarely grants it. Madaya, for example, is less than an hour’s drive from Damascus, yet between July 1, 2015, and January 12, 2016, OCHA could arrange only a single convoy, which contained expired food aid. The last convoy to Duma, where 175,000 civilians have been under siege since November 2012, was on July 2, 2015. Duma is barely ten miles from the Four Seasons in Damascus, where Yacoub El Hillo, OCHA’s resident/humanitarian coordinator, is based.

After the populations held captive by the government, humanitarian need is most acute for the remaining 11 million civilians considered “hard to access”—meaning that they live in territory not controlled by the government, mostly in northern Syria. Of these, some six million people live in areas held by the armed opposition, roughly four million in territory controlled by ISIS, and nearly one million in areas under Kurdish control. Access to these groups occurs mainly across Turkey’s southern border with Syria; help is delivered by tens of thousands of Syrian aid workers supported primarily by Syrian nongovernmental organizations (NGOs) and to a lesser degree by international agencies. The lack of aid from Damascus was recognized when the UN Security Council first authorized cross-border aid in February 2014 with Resolution 2139, but it still sought the Syrian government’s permission. Resolution 2165 in July 2014, requiring only a nominal nod of consent from Damascus, legitimized the humanitarian need across the northern half of Syria and effectively endorsed the efforts by the Turkish government and Syrian NGOs able to deliver aid across the border.

Rebel fighters walk near Red Crescent vehicles on their way to al Foua and Kefraya, in Idlib province, Syria January 11, 2016.
Rebel fighters walk near Red Crescent vehicles on their way to al Foua and Kefraya, in Idlib province, Syria January 11, 2016.
Ammar Abdullah / Reuters

The aid that the UN envisions for these people in 2016 is uneven. Over $1.7 billion of this year’s budget is allocated for UN and national agencies operating from Damascus, all controlled by the government and providing aid almost exclusively to government territory. In nongovernment territory, the UN in Damascus must work through the Syrian Arab Red Crescent. The partisan nature of SARC leadership, which has strong ties to the regime of Syrian President Bashar al-Assad, is evident in the UN’s difficulty in delivering aid from Damascus to nongovernment territory. Between January 1 and August 31, 2015, UN agencies reached an average of four percent of the civilians in besieged areas (about 16,500 people) each month with health assistance, 0.6 percent (roughly 2,500 people) with food, and less than 0.1 percent (fewer than 500 people) with nonfood items such as tents, blankets, and soap.

The defense offered by UN agencies operating in Damascus when challenged for accepting these limitations—that some aid is better than none—is wrong. When the bulk of aid is controlled by the government and is preferentially directed, the main effect is to relieve the government of responsibility for caring for its own citizens, freeing up resources for it to pursue its military strategy of targeting civilians in politically unsympathetic areas, rendering a bad situation there a great deal worse. A principled humanitarian strategy would prioritize need—striving foremost to enter besieged areas and, failing that, to at least prioritize cross-border aid in recognition of those in greatest need.


This month, the UN secretary-general’s High-Level Panel on the Global Response to Health Crises, originally convened to address reform of the World Health Organization (WHO) in light of its weak response to the Ebola virus crisis, extended its focus to the humanitarian emergencies in Syria and other conflict zones. The panel’s wisdom on effective humanitarian action will feed into the secretary-general’s other initiative, the World Humanitarian Summit, organized by OCHA for May 2016. In recent remarks following the two-year consultation leading up to the summit, Stephen O’Brien, the British official heading OCHA, stated that “we need real progress on giving first responders the support they need to enable them to take the lead in preparedness, response and recovery, wherever this is feasible.” He added, “We have heard a clear call for the respect of international humanitarian law and to monitor its application; that we must hold violators to account.”

Yet OCHA’s plan, finalized within weeks of O’Brien’s speech, reveals an organization doing the opposite, still prioritizing relations with Damascus and directing aid to the government rather than to first responders. There was no attempt to highlight, let alone hold the government accountable for, all the blatant violations of international humanitarian law, including the escalating attacks on medics and targeting of hospitals.

These backward priorities are evident in OCHA’s edits of the Humanitarian Response Plan for Syria. The plan was drafted in November, based on the Humanitarian Needs Overview, which itself had previously undergone two revisions. It was already surprising that OCHA began the first version of the overview with a concocted story about six-year-old Khaled, whose father was killed because he could not fit in the basement. An asterisk followed this account, with a note explaining that it was fictional. There are literally millions of real stories of hardship on offer, yet OCHA, evidently operating too far away from those actually in need, had to make one up.

The next draft of the overview contained some interesting statistics and language, such as a reported “91% gap in protection.” Few people would describe 91 percent as a “gap.” A crater, perhaps. A chasm. A void, even. But the euphemism helped gloss over the touchy subject of the cause of this “gap”—the government’s deliberate strategy of attacking civilians in opposition-held areas and OCHA’s failure to challenge it.

By the time the draft response plan was produced, it was already a watered-down document. For example, the number of besieged civilians was underreported at 393,700, and there was no mention of the Syrian government being the main party using siege as a war strategy. The humanitarian hubs in Turkey and Jordan were aware of the plan’s deficiencies but were unable to remedy them. On the upside, their input at least led to considerable programming for the protection of civilians, evident in the extensive demining activities planned for Aleppo and Idlib. The aid provided by national NGOs operating in opposition areas and the considerable cross-border effort from Turkey were recognized, although the Damascus hub refused to acknowledge the population data painstakingly collected by nearly 4,000 Syrian surveillance points, commissioned by OCHA for their Needs and Monitoring Population project. To this point, the Humanitarian Response Plan contains no population total or disaggregation of data for government and nongovernment territory.

OCHA—to be specific, Kevin Kennedy, the regional humanitarian coordinator for the Syria crisis, together with Yacoub El Hillo—then took the draft plan to the Syrian government, which revised the narrative, the budget, and the programming. OCHA acquiesced and edited the document accordingly, presenting the sanitized document on December 7, 2015, with a letter from Hillo stating that “although revised language was included and amendments were made . . . we believe that the document’s credibility and integrity has been preserved.” The revisions resulted in the removal of all references to conflict and hostilities. According to the final Humanitarian Response Plan, there is no war in Syria, only a crisis and insecurity, which, incidentally, is not the government’s fault. The document also minimizes the magnitude of unmet needs by redefining the meaning of protection to exclude civilians as the object of attack and by removing key elements, such as the demining of unexploded ordnance.

Edits to the 2016 Humanitarian Response Plan
Edits to the 2016 Humanitarian Response Plan
Courtesy Annie Sparrow

Once the Syrian government was finished, there were no longer any civilians under siege or even besieged areas, only “locations listed under UN Security Council Resolutions 2139, 2165, 2191.” This is an interesting turn of phrase, given that all these resolutions specifically state that the deliberate starvation of civilians by siege is a war crime under international law. Although attacks against schools (nearly 4,000 since March 2011) and hospitals (over 300) are noted, the reference to the government’s violations of international humanitarian law is deleted.

The same goes for the reference to the United Nations’ monitoring of cross-border relief operations, as required by Resolutions 2165 and 2191. Programming for clearance of land mines, which had already been organized and funded, was removed. The Syrian government was, however, willing to retain education about mines, so at least children—those most at risk—can be sure of the cause of their missing limbs.

Edits to the 2016 Humanitarian Response Plan
Edits to the 2016 Humanitarian Response Plan
Courtesy Annie Sparrow

The Humanitarian Response Plan recognizes only national organizations registered by the government, and it recognizes as “official” only those programs endorsed by the regime. The Syrian government insisted that the humanitarian hub in Turkey responsible for aid across northern Syria be described as providing only cross-border "deliveries" and not "activities," inferring that it has no programming to accompany the aid.

Damascus’ editorial demands undermine the Syrian NGOs that operate in nongovernment territory and provide cross-border aid. Furthermore, despite the authorization of the UN Security Council resolutions, the Humanitarian Response Plan published by OCHA suggests that cross-border aid is illegal and a violation of national sovereignty. Hillo and Kennedy’s acquiescence to these facts is apparent in their letter accompanying the final plan, circulated to the Turkey hub on December 7. OCHA’s cover-up of the critical need in Madaya and the defensive remarks made by Hillo the day after he had witnessed the collective starvation on January 12 further illustrate OCHA’s bias and its consequences.


OCHA is not the only problematic UN agency. WHO has been equally subservient to Damascus. The government covered up the outbreak of polio in the country in 2013 for four months, as WHO stood by. WHO has likewise failed to acknowledge an outbreak of cholera cases in northern Syria even as it has made cholera treatment kits available in government territory.

WHO-SAR map of Syria including Levaa-Eskanderon
WHO-SAR map of Syria including Levaa-Eskanderon.

The extent of WHO Syria’s accommodation to the government is revealed by the multiple reports WHO has published since July 2014 containing maps of Syria, including a province in the northwest that has been part of Turkey since 1939. WHO employs Shukrein Mekhdad, the wife of the Syrian deputy foreign minister, in a technical capacity despite her lack of qualifications in health care, surveillance of disease, or emergency response. In October, WHO defended its substantial overhead charges (15 percent plus) from emergency relief funds to support WHO’s regional office and headquarters for the mere act of channeling $2 million, absent any programming, to the Syrian NGOs actually doing emergency relief. On top of the opacity of WHO overheads, uncovered e-mails revealed the lack of OCHA-WHO communication.


In addition to OCHA’s partiality toward the Syrian government, it has proven particularly susceptible to the government’s invocation of the notion of “Do no harm.” Damascus argues that providing humanitarian services in opposition-held areas is aiding the “terrorists.” It has even referred to health agencies operating in these areas as terrorist agencies. Fearful humanitarian donors are easily influenced by such arguments. ECHO, the European Commission’s department for overseas humanitarian aid and civilian protection, has cited “Do no harm” to justify withholding aid to opposition-held areas, and the Office of U.S. Foreign Disaster Assistance refuses to fund national organizations providing health care, directing funds to UN agencies and international NGOs instead.

Primum non nocere, or “First, do no harm,” widely considered part of the Hippocratic oath, was adopted by the humanitarian industry in the mid-1990s in recognition that conflicts could be made worse and even perpetuated by poorly deployed aid. It has since become received wisdom in the relief community. Except that it’s not a medical principle. Hippocrates didn’t even write in Latin, much less say anything about prioritizing harm avoidance over help. “Do no harm,” first or otherwise, is incompatible with medical practice, public health, and humanitarian aid. Medications and chemotherapy cause side effects. Surgery by definition requires cutting, whether for cataracts or coronary artery bypass. Vaccinations against preventable disease and cancer screening carry risks of pain and bleeding. Aid always has tradeoffs: teachers are lured away from schools to be translators; some aid always ends up on the market.

But in this case, harm is being done with very little help to those who most need it. Syrian NGOs, the only immediate link to the people in opposition-held areas, are already marginalized. They operate from exile in Turkey, forced to learn English because OCHA insists on using it in meetings (an inane practice this far into the Syrian crisis and a disrespectful and exclusive one, given that Arabic is the first language of all the Syrian NGOs) and to abide by OCHA’s often burdensome rules, which prioritize remote oversight over the Sisyphean work for Syrian NGOs actually delivering aid in the midst of a raging war. The Syrian government, having long criminalized doctors for treating civilians in politically unsympathetic areas, now casts medical personnel as international terrorists as well, for the “crime” of working in a territory under the control of armed groups that the regime considers to be “terrorist,” even though the primary purpose of the laws of war is to enable medics to treat, and aid workers to reach, all those in need, no matter who controls the territory.

When OCHA presented its cleansed Humanitarian Response Plan as a fait accompli on December 8, with no transparency about how it was drafted and no opportunity for discussion by nongovernmental Syrian relief workers, it added insult to injury. The Syria NGO Alliance, Syria Relief Network, Syrian Civil Coalition, Union of Syrian Civil Society Organizations, and Syrian General Union wrote a letter in protest to O’Brien on December 30, 2015, expressing specific concerns with the modifications and the humanitarian leadership and requesting a transparent process by which the final decision-making is made without influence from any party to the conflict. WHO has some excuse for its attentiveness to the Syrian government, given that its primary role is to support governments. OCHA, designed to prioritize those in greatest need, does not, and in accommodating the Syrian government it has betrayed the Syrian people. O’Brien’s response on January 17, which neither acknowledges any of the concerns raised nor offers any explanation, reads as both self-congratulatory and superficial. He offers platitudes such as “I can assure you that the UN is [not] too close to any party,” while insisting that in addition to the singular convoys to Madaya and to regime areas in January, “similar efforts continue across Syria on a daily basis, bringing life-saving assistance to millions of people in need.” Given that children are dying daily in Madaya and that Darayya  has not been accessed by the UN since 2012, these all raise further concerns over OCHA’s partiality to the Syrian government.

OCHA’s defense that any aid delivered from Damascus is better than none has not been weighed against the human and financial cost of bolstering a regime that is deliberately increasing the hardship of people in opposition-held areas. Humanitarian aid in such circumstances can sustain the violence that gives rise to the need for aid in the first place. In providing billions of dollars of assistance, the disposition of which is largely dictated by the Syrian government, the UN has freed Syrian government resources to be used for Syrian politicians, troops, security forces, and allies. Someone has to take a stand. At the risk of alienating a key source of financing, the Syrians themselves have now done so. It’s time for OCHA to do its part by revisiting its underlying principles and acting accordingly—to check out of the Four Seasons Hotel in Damascus, to leave the Syrian capital, and to stop supporting the atrocities of the Syrian government.

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  • ANNIE SPARROW, a critical care pediatrician and public health expert, is an Assistant Professor at the Arnhold Global Health Institute at the Icahn School of Medicine at Mount Sinai Hospital in New York City.
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